SESSION I : SENSORY EXAM, MOTOR EXAM, MMSE NEUROLOGIC EXAMINATION (EXAMINATION OF SENSORY FUNCTION) Tests of sensory function are concerned with appreciation of primary or cutaneous sensation and evaluation of cortical integration of sensory impulses. The sensory function is include exteroception sensation tests (light touch, pain and temperature) and propioseption sensation tests. (vibration sense and position sense). I Exteroception sensory examinations. 1 Light touch. The patient sits or lies with hand supinated, and he/she is asked to close the eyes and is instructed to answer “yes” when the stimulus is appreciated. The examiner takes a wisp of cotton and applies it lightly to the skin, and alternates between the two sides, examining the homotropic area The cotton is applied to the skin of the neck beginning in the C3 dermatome on each side and passing down the neck to the shoulder and the lateral aspect of the arm and forearm to the hand. The fingers are tested individually. The stimulus is then applied up the medial aspect of the forearm and upper limb to the chest. Sensation in the lower limb is examined in a similar fashion with an alternating application of the cotton down the lateral aspect of the thigh, leg and foot, and up the medial aspect of the foot, leg and thigh 2 Pain and temperature sensation tests are examined in a similar fashion. Pain sensation is tested with pinwheel or needle. Temperature sensation is tested with glass tube filled with hot or iced water II Propioception sensory examinations. 1 Position sense. Position sense is tested by gently moving a terminal phalanx of toes or fingers The patient is asked to close the eyes The examiner grasps the terminal phalanx in the sides and gently moves it a few degrees in an upward or downward direction. The patient is asked to indicate whether the digit is moved up or down. Compare the two sides with the similar test. 1 2 Vibration sense. The patient is asked to close the eyes The examiner places the base of a tuning fork over a bony prominence. The patient is asked to indicate whether the sensation of vibration is appreciated or not The similar tests are carried out in the other side and compare the both sides. 3 Discriminative sensation (stereognosis) The patient is asked to close the eyes The examiner places in the patient’s hand a familiar object such as a coin, paper clip, key, pencil or cotton ball The patient is asked to tell the examiner what the object is Normally a patient will identify it correctly NEUROLOGIC EXAMINATION EXAMINATION OF MOTOR FUNCTION The examination of motor function include inspection, strength and tones of limbs and percussion for detecting fasciculation The examiner inspects the motor condition of upper and lower extremities. The contour and muscle development of the two side should be equal. During this inspection also detect the muscle wasting, the presence of fasciculation and involuntary movement of the limbs The strength of limbs. The patient is asked to elevate and contract of muscles of upper extremity against resistance of examiner’s hand Test the strength of lower arm flexion (C5-6-biceps) at the elbow : The examiner hold the patient's wrist from above and instruct the patient to flex the hand up to their shoulder. The examiner provide resistance at the wrist. Repeat and compare to the opposite arm. Test the strength of lower arm extension (C6,C7,C8- triceps) at the elbow: the patient is asked to extend their forearm from a fully flexed position against the examiner's resistance. Repeat and compare to the opposite arm. 2 Test the strength of wrist extension(C6, C7, C8, radial nerve): the patient is asked to extend their wrist while the examiner resists the movement. Repeat with the other arm. Test the patient's grip (finger fexion: C8): the patient is asked to hold the examiner's fingers in their fist tightly and instruct the patient not to let go while the examiner attempts to remove them. Normally the examiner cannot remove their fingers. Repeat with the other hand. Test the strength of finger abduction (T1) : the patient is asked to abduct or "fan out" all of their fingers. Instruct the patient to not allow the examiner to compress them back in. Normally, one can resist the examiner from replacing the fingers. Repeat with the other hand. Test the strength of thumb opposition (C8,T1) : the patient is asked to touch the tip of their thumb to the tip of their pinky finger. Apply resistance to the thumb with your index finger. Repeat with the other thumb and compare. The patient is asked to elevate and contract of muscles of lower extremity against resistance of examiner’s hand Test the strength of hip flexion (L2,L3) : the patient is asked to lie down and raise each leg separately while the examiner resists. Repeat and compare with the other leg. Test the strength of legs adduction (L2,L3,L4): the examiner place the hands on the inner thighs of the patient and ask the patient to bring both legs together Test the strength of legs abduction (L4,L5,S1): the examiner place the hands on the outer thighs and ask the patient to move the patient legs apart. Test the strength of hip extension (L4,L5) : the patient is asked to press down the examiner's hand which is placed underneath the patient's thigh. Repeat and compare to the other leg. Test the strength of knee extension (L3,L4) : the examiner place one hand under the knee and the other on top of the lower leg to provide resistance. Ask the patient to "kick out" or extend the lower leg at the knee. Repeat and compare to the other leg. Test the strength of knee flexion (L5,S1) : the examiner hold the knee from the side and apply resistance under the ankle. The patient is asked to pull the lower leg towards their buttock as hard as possible. Repeat with the other leg. 3 Test the strength of ankle dorsiflexion (L4,L5): the examiner hold the top of the ankle. The patient is asked to pull their foot up towards their face as hard as possible. Repeat with the other foot. Test the strength of ankle plantar flexion (S1,S2): the examiner hold the bottom of the foot. The patient is asked ask to "press down on the gas pedal" as hard as possible. Repeat with the other foot and compare. Test the strength of extensor halucis longus muscle (L5) : The patient is asked to move the large toe against the examiner's resistance "up towards the patient's face". The examiner notices the grade of strength of limbs. Grade 5. The patient can against the full resistance of the examiner’s hand equally (normal patient). Grade 4. The patient can against only light resistance of the examiner'’ hand. Grade 3. The patient can only against the gravitation resistance. Grade 2. The patient can only move the limbs over the bed. Grade 1. The patient cannot move the limbs but just move the fingers. Grade 0. The patient is total paralysis (paraplegia) The same manner for examining the lower extremity. The tone of muscles The patient is asked to relax the muscles of limbs The examiner flex and extend passively the patient’s joint of limbs and felt the muscle resistance, Abnormal response is the increased of tonicity of the muscles. Comparing the tone’s limb muscles of two side The fasciculation The examiner percuss on one area of limbs. The examiner notice the fasciculation moving of the muscles on the area of examination (Fasciculation is the contraction of some group of muscles) 4 NEUROLOGIC EXAMINATION MINI MENTAL STATE EXAMINATION ( MMSE ) Orientation Time : Year Month Day Date Time ( 1 point for each correct ) Place : Country Town District Hospital Ward ( 1 point for each correct ) Registration Examiner names 3 objects (e.g. Apple, Table, Penny) Patients ask to repeat (1 point for each correct) THEN patients to learn the 3 names repeating until correct Attention and Calculation Subtract 7 from 100, and then repeat for results. Continue 5 times : 100 93 86 79 65 Alternative : Spell “WORLD” backwards , “DLROW” (1 point for each correct) Recall Ask for names of three objects learned earlier (1 point for each correct) Language Named a pencil and watch (1 point for each correct) Repeat : No if, ands, or buts (1 point if correct) Give a 3 stage command. (Score 1 point for each stage correct) Eg. “Place index finger of right hand on your nose and then on your left ear”. Ask patients to read and obey written command on a piece of paper stating “ Close your eyes” (1 point if correct) Ask the patients to write a sentence. (Score 1 point if it is sensible and has a subject and a verb) Copying Ask the patients to copy a pair of intersecting pentagons. ( 1 point if correct ) TOTAL = 5 + 5 + 3 + 5 + 3 + 2 + 1 + 3 + 1 +1 +1 = 30 5 CRANIAL NERVES EXAM, GCS NEUROLOGICAL EXAMINATION CRANIAL NERVES 1 N.I. (OLFACTORY NERVE) The patient is asked to inhale with one nostril occluded The examiner brings the test substance close to the no occluded side. The test substance : - must be nonirritating - such as coffee, tobacco, tea Each nostril is test separately The examiner notes that inhalation is adequate, and then requests the patient to identify the test substance. 2 N.V (TRIGEMINAL NERVE) Examination of N.V includes: - evaluation of corneal reflex - sensation of the face and scalp - motor function - the jaw reflex 2.1 Evaluation of corneal reflex (This reflex is tested by the light application of cotton to the cornea) The examiner takes a cotton applicator and pulls the cotton head into a fine point.